APPLICATION FOR EMPLOYMENT

FOR YOUTH DEVELOPMENT FOR HEALTHY LIVING FOR SOCIAL RESPONSIBILITY

The YMCA has zero tolerance for abuse of children, seniors and other vulnerable individuals and inappropriate behavior by staff members.
DRUG-FREE WORKPLACE
EQUAL OPPORTUNITY EMPLOYER
APPLICATION FOR EMPLOYMENT
VOLUSIA FLAGLER FAMILY YMCA

YMCA CAMP WINONA
DATE

MonthDayYear
Date
POSITION(S) APPLIED FOR
YMCA FAMILY CENTER
REFERRAL SOURCE
Referral Source

AdvertisementFriendRelativeEmployment AgencyOther
Other
BASIC INFORMATION
LAST
FIRST
MIDDLE
OTHER NAMES USED DURING PRIOR EMPLOYMENT. ie. Nickname, Maiden name etc.
STREET ADDRESS
APT. NUMBER
CITY
STATE
ZIP CODE
HOME PHONE
CELL PHONE
Email
example@example.com
Are you at least 16 years old?

YesNo
Are you at least 18 years of age by start of employment?

YesNo
Have you ever been employed by the Volusia Flagler YMCA or any other YMCA?

YesNo
If you have ever worked at the YMCA before; where, what dates and what positions?
Have any of your relatives ever worked for this organization?

YesNo
If yes, which family center and department?
PRINT LAST NAME
Have you ever been convicted of a crime, pled no contest, had adjudication withheld, or are you the subject of pending charges?

YesNo
Conviction of a crime will not necessarily disqualify you from employment. Factors such as age at the time of offense, type of offense, remoteness of the offense, and rehabilitation will be taken into account in determining effect on suitability for employment. Failure to disclose information, however, may disqualify you from further consideration.
If yes, please explain
Where
Date

MonthDayYear
Date
The YMCA hires only U.S. citizens and lawfully authorized alien workers. If a conditional offer of employment is made, you will be required to provide proof of citizenship or authorization to work in the U.S.

Are you a U.S. citizen or are you legally authorized to work in the U.S.?
YesNo
Have you ever worked in a childcare facility that has had a license denied, revoked or suspended in any state or jurisdiction; or have you been the subject of a disciplinary action or been fined while employed in a child care facility?
YesNo
If yes, please provide date, charge and comment:
EDUCATION
Awards, scholarships, honors received
Name of High School
College or University
Course of Study
Vocational School
Degree/Level of Education
SKILLS/CERTIFICATIONS/RELEVANT TRAINING
Please check all that apply. Examples: CPR, First Aid, Lifeguard, Group Exercise, Nursing, Etc.

LICENSING/CERTIFICATION AGENCY
Certifications
Licensing Agency
Date Received

MonthDayYear
Date
Number
PRINT LAST NAME
Expiration

MonthDayYear
Date
SKILLS/CERTIFICATIONS/RELEVANTTRAINING
Other
REFERENCES
Please list three personal or professional references that we can contact, one of which can be family, if possible.
NAME #1
RELATION
EMAIL
example@example.com
PHONE
NAME #2
RELATION
EMAIL
example@example.com
PHONE
NAME #3
RELATION
EMAIL
example@example.com
PHONE
EMPLOYMENT EXPERIENCE
List present and past employment beginning with most recent. Include Military Service assignments.

Check here if you have no previous employment experience.
Employer #1
Address
Starting Date
End Date
Job Title
Supervisor
Supervisor's Phone
Salary
Hours per week
Work Performed
Reason For Leaving
Employer #2
Address
Starting Date

MonthDayYear
Date
End Date
Supervisor
Job Title
Supervisors Phone
Salary
Hours per week
Work Performed
Reason for leaving
Employer #3
Starting Date
End Date
Address
Job Title
Salary
Supervisor
Supervisor Phone
Hours per week
Work Performed
Reason For Leaving
If needed, attach additional sheets, using the same format as on the application.
APPLICANT'S CERTIFICATION & AGREEMENT
PLEASE READ CAREFULLY BEFORE SIGNING

I am aware that any omissions, falsifications, misstatements, or misrepresentations on this application may disqualify me for employment consideration and, if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability, criminal record, driving record, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel staff, and other authorized employees of the Volusia Flagler Family YMCA for employment purposes. This consent shall continue to be effective during my employment if I am hired. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith.
APPLICANT SIGNATURE

Clear
Print Signature
DATE

MonthDayYear
Date
PARENT'S OR GUARDIAN'S SIGNATURE (IF APPLICANT IS LEGALLY A MINOR)
Signature

Clear
DATE

MonthDayYear
Date
Should be Empty:

DRUG-FREE WORKPLACE

EQUAL OPPORTUNITY EMPLOYER

APPLICATION FOR EMPLOYMENT

VOLUSIA FLAGLER FAMILY YMCA

REFERRAL SOURCE

BASIC INFORMATION

EDUCATION

SKILLS/CERTIFICATIONS/RELEVANT TRAINING

SKILLS/CERTIFICATIONS/RELEVANTTRAINING

REFERENCES

EMPLOYMENT EXPERIENCE

APPLICANT'S CERTIFICATION & AGREEMENT